Nokea
Which of the following is the highest level of human need according to Maslow (1968)?
- A. Physiologic
- B. Love and belonging
- C. Esteem and self-esteem
- D. Self-actualization
Correct Answer: D
Rationale: The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
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The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing interventions. What would be an appropriate nursing intervention for this client?
- A. Force fluids.
- B. Offer the client 100 mL of fluid every hour while awake.
- C. Offer fluids prn.
- D. Give adequate amounts of fluid throughout the day.
Correct Answer: B
Rationale: Nursing interventions are specific nursing directions so that all healthcare team members understand exactly what to do for the client. Different people are likely to interpret a vague nursing order such as 'Encourage fluids' differently, resulting in inconsistent care. The other answers are not specific and are open to different interpretations. Forcing a client to do anything is not therapeutic or ethical for nurses.
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
The nurse understands that critical thinking skills are an integral part of nursing practice. Development of these skills requires what from the nurse?
- A. Intention
- B. Experience
- C. Contemplation
- D. Focus on outcomes
Correct Answer: B
Rationale: Nurses develop critical thinking skills through knowledge, experience, and practice. Intention, contemplation, and a focus on outcomes are characteristics of critical thinking. They are not how the nurse develops critical thinking skills.
Which of the following is involved in the implementation step of the nursing process?
- A. Selecting nursing interventions
- B. Documenting nursing care and client responses
- C. Documenting the plan of care
- D. Identifying measurable outcomes
Correct Answer: B
Rationale: The implementation step in the nursing process involves documenting nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.
The LPN is assisting with the admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process?
- A. Gathering more extensive biopsychosocial data
- B. Drawing conclusions, uses judgment, and makes diagnosis
- C. Establishing priorities, sets short- and long-term goals
- D. Contributing to the development of care plans
Correct Answer: D
Rationale: The role of the LPN allows for the contribution of the development of care plans. The other answers are within the scope of practice of an RN.